Comments to ONC: PCAST HIT Report Becomes a Political Piñata

The PCAST Report on Health IT has become a political piñata. 

Early Feedback on PCAST 

Like many of my colleagues, I was taken aback by the release of the Report in early December 2010 — I didn’t know quite what to make of it. Response in the first week of release was: 
  • Limited. The first commentaries were primarily by technical and/or clinical bloggers. The mainstream HIT world had remarkably little initial reaction to the Report. 
  • Respectful of the imprimatur of “The President’s” Report and noting some of the big names associated with the report (e.g., Google’s Eric Schmidt and Microsoft’s Craig Mundie.)
  • Focused on technical and/or clinical perspectives around two broad themes.
    • The vision is on target:  “extraordinary”, “breathtakingly innovative”.
    • These guys didn’t do all their technical homework. The range varies, but the message is consistent. 

Today’s POV on PCAST 

What  a difference a six weeks makes. 

Is HITECH Working? #3: ONC got it right on the 3 major policy interpretations: Meaningful Use, Certification, Standards

We concluded our last post in this series with a blunt prediction that “key physicians will sit on the sidelines” and that clinician non-adoption of EHR technology is a potential “deal-breaker for the success of HITECH”.

While this might sound like a criticism of the way HITECH has been implemented, it’s not intended that way — it’s a commentary on 1) the complexity and scope of change that will be required to make HITECH successful, and 2) the level of protective entrenchment existing American health care today.

Rather, we believe that the Office of the National Coordinator (ONC) for Health IT – Dr. David Blumenthal and his staff — have done a superb job in interpreting and defining key aspects of HITECH legislation. We’re big fans.

For those of you who have been following our writings over the past 18 months, think of this post as a summary and status report on the extensive incumbent (cat) vs. innovator (dog) dialogue:

  1. A Recap  — The Stagnant Electronic Medical Record (EMR) Market Before 2009
  2. ONC Gets It Right In Three Major Interpretations and Definitions of HITECH

a) Meaningful Use (MU) Emphasizes “Meaningful”, Not “Use”

b) Vendors Get a Level Playing Field With Certification

c) Lightweight, Open Standards Promote EHR Interoperability and Modularity

Is HITECH Working? #2: Key physicians will sit on the sidelines (at least for now).








(click on any of the above graphics to be linked to the orginal source)

by Vince Kuraitis JD, MBA and David C. Kibbe MD, MBA

In the previous post in this series on “Is HITECH Working?”, we straightforwardly noted that hospitals are playing in the HITECH game. The issue of whether physicians will play is MUCH thornier.

As the headlines above succinctly convey — we conclude that for now there is too much fear, uncertainty, and doubt (FUD) to expect significantly increased EHR technology adoption by most physicians from the HITECH incentives and penalties.

Here are topics we’ll cover today:

  • Fear, Uncertainty, Doubt
  • Little Risk by Waiting a Year or Two
  • A More Granular View — Segmenting Physicians
  • Is There Another Side to the Story?
  • How Important is Physician Adoption to the Success of HITECH?

A Compendium of Perspectives on the HITECH Certification NPRM

Just the Facts 

Certification Programs NPRM (Notice of Proposed Rulemaking)

Health IT, U. S. Department of Health and Human Services; March 2, 2010

Certification NPRM




Bookmarked version of Certification NPRM (much easier to navigate)

U. S. Department of Health and Human Services; March 2, 2010

Via OCCAM Practice Management blog, March 3, 2010


Commentary and Analysis


Proposed EHR Certification Rule Changes Game

HDM Breaking News; March 2, 2010

“The rule mentions the Certification Commission for Health Information Technology, but does not grant it any grandfather status…. So, while CCHIT appears to be able to continue its operations under the proposed temporary certification program, its future isn’t clear in the proposed permanent program.”


Certification NPRM: A Statement from Alisa Ray, Executive Director, Certification Commission for Health Information Technology (CCHIT)

EHR Decisions; March 3, 2010

“…we feel confident about our prospects of becoming accredited…. We feel confident about the future, and we look forward to the opportunity to continue playing a role in accelerating the adoption of health IT.


 Why Rush Vendor Certification of EHR Technologies?

The Health Care Blog; March 08, 2010

“David Blumenthal and his staff have unveiled two separate plans to test and certify EHR technology products and services. We don’t think this is a good idea…this recently-announced two-stage EHR technology certification plan bears all the marks of a hastily drawn up blueprint that, if rushed into production, could easily collapse of its own bureaucratic weight.”


HIT Leaders React to Proposed EHR Testing and Compliance Rule

HealthLeaders Media; March 4, 2010

  • “They got it exactly right.” Simeon Schwartz, MD, president and CEO of WestMed Medical Group.
  • “It’s going to be interesting to see how much the vendors got out ahead of this and how much they’ve hedged their bets” Eric Saff, CIO of John Muir Health
  • “…no matter where you are in the chain of this market, you can in fact certify those modules as opposed to waiting until you meet complete meaningful use to be certified. So I think that’s great. I think that’s really considerate of the ONC.” Luigi Leblanc of Solink

Chilmark Needs to Chill Out on CCR/CCD Findings

John Moore of Chilmark Research and I agree on things 90+ percent of the time. He even thanked me personally for our collegial relationship in a Thanksgiving Day essay on his blog.

However…I can’t help but comment on John’s misleading story “CCD Standard Gaining Traction, CCR Fading” in The Health Care Blog. He writes:

In a number of interviews with leading HIE [Health Information Exchange] vendors, it is becoming clear that the clinical standard, Continuity of Care Document (CCD) will be the dominant standard in the future.  The leading competing standard, Continuity of Care Record (CCR) appears to be fading with one vendor stating that virtually no client is asking for CCR today.

I have four beefs with John’s essay:

  1. It’s no news that HIEs prefer CCD.
  2. HIEs are not representative of the broader health IT market.
  3. The narrow findings don’t justify the broad conclusion.
  4. The CCD and CCR standards are more complementary than competitive

Let’s look at these one at a time.

John Halamka’s Stunning 180: “Dogs and Cats Should Live in Harmony”

The King of the Cats has just acknowledged that indeed cats and dogs should co-exist peacefully.

Dr. John Halamka — Vice Chair of the HIT Standards Committee of the ONC and one of the most vocal and influential figures in health IT — writes a blog post this morning entitled “The Genius of AND”. Halamka reasonably summarizes the essence of the debate about standards and interoperability as being between “the healthcare informatics crowd” (cats) and the “Internet crowd” (dogs):

He notes that the debate shouldn’t be about one or the other POV prevailing (“either/or”), but about integrating both points of view (“and”):

..we need to embrace both approaches – the right tool for the right job depending on what you want to achieve.

For provider to provider communication which requires the exchange of documents with non-repudiation as the medico-legal record for direct clinical care, the CDA/CCD has great metadata and the ability to support structured data as well as free text discharge summaries/operative notes/history&physicals.

For a summary record that represents a snapshot in time of problems, medications, and labs for transmission between EHRs and PHRs, the CCR and other formats such as Google’s CCRg or PDF can do the job.

I’m absolutely stunned…and speechless.

The Third Rail in HITECH Implementation: “Please Don’t Make Us All Speak Latin”

By Vince Kuraitis and Steven Waldren MD, MS.  Dr Waldren is Director of the Center for Health Information Technology at the American Academy of Family Practice (AAFP).

Two issues have rightfully surfaced front and center in the public’s understanding of HITECH Act implementation:

  • ” definition of “Meaningful Use” of EHRs, and
  • ” definition of “certification” process for EHRs

…and we applaud the progress of the workgroups and the HIT Policy Committee in addressing these issues constructively.

However…a THIRD issue lurks – “Data harmonization at the expense of data liquidity“, or put another way – “misplaced pursuit of one (and only one) language at the expense of practical communication.”

On August 20, the HIT Standards Committee approved recommendations to bring forward to the HIT Policy Committee meeting later this September. 

In this post, we will:

  1. Summarize aspects of the HIT Standards Committee’s recommendations that are problematic
  2. Develop an analogy to illustrate how the recommendations will limit innovation and increase barriers to communication.  Our analogy:

The Standards Committee recommendations are like mandating that everyone in the U.S. be required to speak Latin by 2013.


Dr. Blumenthal has wisely anticipated that there could be a situation where in his role as national coordinator that he should not follow a Committee’s advice:

“This committee does provide advice to the national coordinator, but it does not make policy,” Blumenthal said, with a noticeable emphasis on “not.” [iHealth Beat; August 18, 2009]

Dr. Blumenthal, this is exactly the situation you have anticipated.

CMS Releases 2nd Report on Medicare Health Support

by Vince Kuraitis and Thomas Wilson, PhD, DrPH

CMS has just released the 2nd Report to Congress evaluating the Medicare Health Support (MHS) program. MHS is Medicare’s most visible and significant demo focusing on chronic disease management.

We’ve been poring over the report and will provide more detailed analysis and implications later this week. This 2nd Report to Congress covers 18 months of data on this 3 year project. It provides far more details and substantiation than RTI’s first report, which only covered 6 months data.

However, there’s nothing in here to change our January 2008 conclusion:  The rumors of MHS’s death have NOT been greatly exaggerated.

Here are the five key findings:

Leavitt’s Framework Shoehorns the HIPAA Privacy Rule onto Your Personal Health Information


by Vince Kuraitis and David C. Kibbe MD, MBA

Have you ever heard anyone tell a happy story of how easy it is to get a copy of their paper medical records?

Departing Health and Human Services Secretary Mike Leavitt is laying the groundwork for this same story to apply to access to YOUR electronic personal health information.

Here’s an overview to what evolved into a long posting:

  1. Analysis: The Leavitt Framework Uses the HIPAA Privacy Rule as a Baseline for Electronic Access to Personal Health Information
  2. Implication: Extending the HIPAA Privacy Rule Could Restrict Your Electronic Access to Your Personal Health Information
    • A.The HIPAA Privacy Rule Should Not Be the Baseline for Governing Access to Your Personal Health Information
    • B. Examples: Extending the HIPAA Privacy Rule Creates Barriers and Confusion
  3. Implication: Extending the HIPAA Privacy Rule Protects Incumbents at the Expense of Innovators Like Microsoft and Google
  4. Conclusion: The Leavitt Framework Creates Bad Public Policy

Complimentary Webinar on Comparative Effectiveness Sponsored by Population Health Impact Institute (PHII)

The message is clear from Washington – “Comparative Effectiveness” has been proposed as the foundation for coverage decisions in Medicare.  As the feds lead – this will more than likely "trickle down" to the commercial sector.

The Population Health Impact Institute (PHII) has convened national experts to develop a practical, comparative-based system to help purchasers and payers evaluate the methods and results used in all kinds of population health management programs – including medical, case and disease management, benefit design, value-based purchasing and more.

Join us on Thursday, December 18 at 2:00 pm (EST) for a one-hour complimentary webinar to learn more about the PHII Methods Evaluation Process™ (MEP), including the: